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Vol 10, No 4, July/August 2002
249
Total hip arthroplasty (THA) is the
standard of care for severe osteo-
arthritis (OA) of the hip, especially
in patients older than 50 years. In
adolescents and young adults (16 to
30 years old), however, long-term
durability and the prospect of mul-
tiple revisions are a concern.
1
Treat-
ment should relieve symptoms yet
allow for as many options as possi-
ble in the future. For early OA of
the hip, proximal femoral and
pelvic osteotomies preserve bone
stock and delay or even prevent
THA.
2
However, disabled patients
with severe OA who desire to re-
turn to an active lifestyle also may
opt for a THA.
3
Hip arthrodesis is
not generally perceived as a favor-
able alternative by surgeons or by
patients with severe OA because of
the dramatic and immediate relief
of pain and good functional results

of joint replacement. Hip fusion is
perceived as having functional out-
comes inferior to those of THA.
However, the long-term results of
THA in this population have been
disappointing, with revision rates of
33% to 45%.
4-7
In these studies,
4-7
active patients with unilateral hip
disease secondary to osteonecrosis
and OA had poorer results than did
patients with inflammatory condi-
tions.
Long-term clinical data are insuf-
ficient to assure prolonged sur-
vivorship from newer techniques
such as cementless fixation
8
or from
implants utilizing alternate bear-
ings. The latter includes highly
cross-linked polyethylenes,
9
which
may reduce the extent of peripros-
thetic bone loss and osteolysis
induced by wear debris.
10

The sur-
geon is left with three choices: (1)
delaying surgery by use of nonsur-
gical modalities, such as a cane and
medications; (2) performing a THA;
or (3) undertaking a bone-conserving
procedure such as a hip arthrodesis
or osteotomy. Delaying surgery
relegates the patient to a more
sedentary lifestyle. A THA pro-
vides reliable pain relief but puts
the patient at risk for multiple revi-
sion surgeries. A hip arthrodesis,
when done correctly, provides pain
relief, enables an active lifestyle, and
may permit later conversion, if in-
dicated, to a THA with minimal
morbidity. Arthrodesis may be con-
sidered as an option because of the
long life expectancy of young pa-
tients, the potential for failure of pri-
mary hip replacement, and the
increased risk and limited durability
of revision surgery.
Dr. Beaulé is Assistant Clinical Professor, Joint
Replacement Institute at Orthopaedic Hospital,
Los Angeles, CA. Dr. Matta is Clinical Pro-
fessor, Department of Orthopaedic Surgery,
University of Southern California, Los Angeles.
Dr. Mast is Director, Bioregenerative Center,

Northern Nevada Medical Center, Sparks, NV.
Reprint requests: Dr. Beaulé, Joint Re-
placement Institute at Orthopaedic Hospital,
2400 South Flower Street, Los Angeles, CA
90007.
Copyright 2002 by the American Academy of
Orthopaedic Surgeons.
Abstract
The management of young adults with severe osteoarthritis of the hip
remains a problem because of the increased failure rates of total hip arthro-
plasty (THA) as well as the prospect of multiple revisions in this population.
Although hip arthrodesis is not perceived favorably as an alternative by most
orthopaedic surgeons or patients because of the presumption of less than opti-
mal functional outcomes, it is a viable technique, especially for younger
patients with a recent history of local infection and/or trauma. With current
internal fixation techniques, a fusion rate >80% can be achieved with maxi-
mal preservation of bone stock. Proper patient selection and optimal
arthrodesis position (flexion of 20° to 30°, adduction of 5°, external rotation
of 5° to 10°, and limb-length discrepancy <2 cm) are essential for a success-
ful, long-term result. Back and ipsilateral knee pain are the most common
complaints leading to secondary conversion of a hip fusion to a THA.
Symptoms improve markedly after conversion. Survivorship of the conver-
sion THA is comparable to that of a primary THA when the patient is older
than 50 years of age and multiple surgical procedures have been avoided.
However, the procedure can be technically challenging and has a high risk of
postoperative complications.
J Am Acad Orthop Surg 2002;10:249-258
Hip Arthrodesis: Current Indications and Techniques
Paul E. Beaulé, MD, FRCSC, Joel M. Matta, MD, and Jeffrey W. Mast, MD
Results of Hip Arthrodesis

The initial reports of the results of
hip arthrodesis had short-term
follow-ups
11
and focused mainly
on fusion rates with different tech-
niques (extra-articular versus intra-
articular, with or without internal
fixation). Indications included
tuberculosis in younger patients
and degenerative arthritis in older
patients. Two early series that re-
viewed the initial results of internal
fixation reported fusion rates of 74%
to 78%; surgical technique had the
greatest influence on outcome.
12,13
The overall long-term results of
hip arthrodesis (Table 1) depend on
proper surgical technique, adequate
hip positioning, minimal limb-length
discrepancy, and proper patient
selection. When these factors are
favorable, incidence and onset of
pain in adjacent joints can be signifi-
cantly minimized, and most patients
are able to return to an active life,
including manual labor. Female
patients tend to do as well as male
patients, with no reported difficulties

with childbirth. However, the sur-
geon and the patient must be aware
of the limitations imposed by the
fused hip on activities of daily living
as well as sexual activity, particularly
when other joints become involved.
The most important elements in the
assessment of hip arthrodesis are
functional outcome and the effect on
adjacent joints (contralateral hip,
ipsilateral knee, and lower back).
Function and Gait
Several authors
14-17
have reported
satisfactory long-term function after
hip arthrodesis, with most patients
employed and able to walk more
than 1 mile. An average of 75% of
patients reported adequate pain re-
lief. However, 32% experienced dif-
ficulties with sexual activity, and
more than 70% graded their activity
as below average for their age
group, although female patients
younger than 18 years of age fared
better than older female patients.
Two smaller series of young adults
with long-term follow-up
18,19

also
reported that most patients had ade-
quate pain relief, were able to return
to work, and would consider a hip
fusion again. However, these pa-
tients had difficulty putting on
shoes and socks
18
and had some
degree of sexual impairment.
19
In a series of 40 Asian patients
with hip fusion,
16
35 (87.5%) claimed
that the arthrodesis limited bending
during Japanese-style sitting. Other
common activities affected putting
on and taking off socks, standing,
climbing stairs, and sexual activity.
All patients returned to their previ-
ous jobs, even those doing heavy
labor.
20
Ahlbäck and Lindahl
21
reviewed
35 patients with a minimum 2-year
follow-up. Gait was judged from an
aesthetic standpoint only. Sitting

was based on the patient’s activities
of daily living. Alignment in the
frontal plane (abduction/adduc-
tion) had the greatest effect on gait
because of its relationship to limb-
length equality. The patients with a
hip fused in 40° of flexion, a contra-
lateral hip with a flexion-extension
arc ≥80°, and a lumbar spine with
40° of motion exhibited the best
gait. Gore et al
22
provided a more
detailed analysis of gait following
unilateral hip fusion after reviewing
28 men (average age, 35 years) at 6
years. A consistent gait dysrhythmia
was observed secondary to a short-
ened stance phase and prolonged
swing phase for the fused hip com-
pared with the mobile contralateral
hip. Patients also exhibited a slower
gait velocity because of a shortened
step length. To substantially in-
crease stride length, patients exhib-
ited a greater than normal anterior
pelvic tilt, which caused the lumbar
spine to remain in varying degrees
of lordosis throughout the gait cycle.
The effective increase in lordosis and

change in pelvic tilt resulted in the
mobile hip having a greater flexion-
extension excursion than normal.
Also, real inequality in limb length
(shortening of the fused side) as well
as effective inequality (the hip po-
sition in the frontal plane caused by
adduction >10°) adversely affected
walking performance. The greater
the inequality, the more irregular the
forward progression, causing greater
lateral motion of the head and trunk
and a tendency to walk slower.
A recent study by Karol et al
23
confirmed the findings of Gore et
Hip Arthrodesis
Journal of the American Academy of Orthopaedic Surgeons
250
Table 1
Long-Term Results of Hip Arthrodesis
Mean (yr) Pain
Patient Age Low Ipsilateral Contralateral Conversion
Study at Arthrodesis Follow-up Back (%) Knee (%) Hip (%) to THA (%)
Sponseller et al
14
(53 hips) 14 38 57 45 17 13
Callaghan et al
15
(28 hips) 25 37 61 57 26 21

Sofue et al
16
(40 hips) 32 26 65 35 19 0
al
22
that increased motion of the
lumbar spine and ipsilateral knee
had a negative effect on the gait of a
shortened, fused limb. Average age
at the time of fusion in nine patients
was 13 years. At an average follow-
up of 8 years, seven patients reported
earlier onset of back pain than in
other series. The earlier onset of
back pain was thought to be due to
the younger age as well as higher
activity level of the patients. Five pa-
tients had good to excellent results.
Contralateral Mobile Hip
A review
17
of 125 patients (mean
age, 52 years) with fused hips at an
average 10-year follow-up revealed
that those whose mobile hips showed
a high probability of arthritic deteri-
oration
24
(ie, asymptomatic hip dys-
plasia) had an inferior functional

outcome and the lowest rate of
restored working capacity. These re-
sults were thought to be secondary
to the added stresses placed on the
mobile hip during gait with a unilat-
eral fusion. In another series,
16
22.5% of patients with preexisting
osteoarthritic changes and/or a
diagnosis of developmental dyspla-
sia of the noninvolved hip had pro-
gression of disease.
Ipsilateral Knee and Lower Back
Examining the knees of 200 pa-
tients (mean age, 52 years) with
unilateral hip fusion at an average
follow-up of 22 years, Hauge
25
noted radiographic evidence of os-
teoarthritic changes in 65% of pa-
tients, with 51% exhibiting genu
valgum. Most (96%) demonstrated
some form of frontal or rotatory in-
stability, with more than 20% of the
majority complaining of knee pain
or instability. No direct correlation
was made between position of the
fused hip and its potential effect on
the ipsilateral knee. The deteriora-
tion and symptoms in the ipsilateral

knee were related to the rotational
strain placed on the knee during the
stance phase when, after the foot is
placed flat on the ground, the knee
compensates for the increased trans-
verse pelvic rotation. These find-
ings were similar to those of Spon-
seller et al
14
and Callaghan et al,
15
who reported that 57% to 61% of
patients had pain in the lower back
and ipsilateral knee. A markedly
higher incidence was noted in pa-
tients with malpositioning of the
fused hip (excessive abduction). In
an earlier study with an average
follow-up of 4.4 years, Price and
Lovell
26
reported on 14 patients
less than 15 years old. This group
had more favorable functional
results, with only one patient com-
plaining of ipsilateral knee pain.
THA After Hip Arthrodesis
The primary indications for con-
version of a hip fusion to THA are
pain in the lumbar spine, ipsilateral

knee, and contralateral hip. The
ability to alleviate the symptoms as
well as provide a functional THA
at a later date is an important con-
sideration when discussing the long-
term outcome of a hip fusion with
a patient.
Hardinge et al
27
reviewed 112
hips (104 patients) converted to
THA after spontaneous or surgical
fusion, excluding ankylosing spon-
dylitis (Table 2). After an average of
25 years of fusion, the indications for
conversion were pain in the lumbar
spine (71% of patients), ipsilateral
knee (48.1%), contralateral mobile
hip (34%), and sound, fused hips
with no evidence of spinal degenera-
tion (9.8%). Limb-length discrepancy
>2 cm was present in 67% of pa-
tients before conversion and in only
11.5% after THA. Patients whose
hips were fused before puberty had
less improvement in hip muscle
function because of underdevelop-
ment of the greater trochanter. Only
5% of patients were dissatisfied with
their results. Optimum scores on

hip evaluation were not achieved
until 18 to 24 months after conver-
sion. Strathy and Fitzgerald
28
re-
ported on the long-term follow-up of
80 hips after conversion and identi-
fied several risk factors for an early
failure: surgical fusion (48.5% failure
rate versus 5% when no previous
surgery was done), more than two
surgeries, and patient age of 50 years
or less at the time of conversion THA.
In a more detailed analysis, Kilgus
et al
29
reported on 41 hips in 38
patients. Sixty-eight percent were
spontaneous fusions that had re-
mained fused for an average of 33
years compared with an average of
18 years for the 32% that were surgi-
cally fused. A variety of total hip
designs was used, including three
surface arthroplasties. At the time of
conversion, 68% of patients com-
plained of nonradicular and activity-
related back pain, and 50% com-
plained of loss of function from
immobility or malposition of the

fused hip. Incidence of pain in the
ipsilateral knee and fused hip was
42% and 16%, respectively, and 8%
in both the contralateral knee and
hip. The results demonstrated that
a higher percentage of patients ob-
tained relief of back symptoms
compared with relief of pain in the
ipsilateral knee, fused hip, or con-
tralateral knee and hip. The range of
motion was slightly less than that
after primary THA. Correction of
limb-length discrepancy was an
important element in overall patient
satisfaction. Interestingly, the UCLA
hip function scores before and after
THA were not significantly different,
reflecting the high level of function
preoperatively and the patients’ per-
ception of a satisfactory result (ie,
relief of back pain, correction of
limb-length discrepancy). Only 33%
of patients used a less restrictive
device (for example, a cane instead
of a crutch, or one crutch instead of
two) for postoperative ambulation.
Postoperatively, patients continued
to improve functionally for up to 2
years. The two most important fac-
Paul E. Beaulé, MD, FRCSC, et al

Vol 10, No 4, July/August 2002
251
tors for postoperative abductor mus-
cle strength were preoperative quali-
ty and mechanical restoration of the
abductor lever arm. The failure rate
of the THA at a mean follow-up of 7
years (range, 2 to 16.5 years) was 8%
for spontaneous fusion versus 23%
in the surgically fused hips. Other
risk factors for earlier failure were
age less than 45 years at the time of
THA and patients with two or more
operations before conversion.
Reikerås et al
30
reviewed 46 con-
versions, with the indications for sur-
gery being pain in the lower back
and ipsilateral knee, as well as loss of
function from immobility or malpo-
sition of the fused hip. Eighty-five
percent of patients were satisfied
with the outcome at a mean follow-
up of 8 years. Poor results (eg, pa-
tients who used walking aids post-
operatively or had poor abductor
muscle function) were associated
with a long duration of fusion and
older age at the time of fusion. The

common preoperative complaints of
the 37 women in the group were dif-
ficulties with sexual intercourse and
wetting the inside of the thigh dur-
ing urination, both probably second-
ary to the excessive adduction of the
fusion. These problems resolved after
conversion.
Hamadouche et al
31
reported on
45 hips after conversion, all done
through a transtrochanteric approach,
with a mean follow-up of 8.5 years.
The indication for conversion was
pain in the neighboring joints (ie,
knee and lumbar spine). The only
predictive factor of functional result
with regard to the walking ability
was the preoperative status of the
gluteus muscles, which is best evalu-
ated preoperatively by palpation of
the contracting abductor muscles.
Survivorship of hips that fused
spontaneously (excluding ankylos-
ing spondylitis) versus surgically
was 94.6% versus 83.5% at 10 years
(NS). Because abductor muscle con-
traction is related to postoperative
outcome,

32
Hamadouche et al felt
that conversion should not be done
if adequate abductor function is not
present and the hip is in satisfactory
position.
Kreder et al
33
reviewed the com-
plication rate of 40 conversions after
hip arthrodesis done with a variety
of surgical techniques during a 3-
year period. The conversions, which
represented only 0.3% of the 12,952
THAs performed, had an overall
complication rate of 45% compared
with 11% for primary THA. The re-
vision and infection rates at 4 years
were also much higher (10% for con-
version versus 2% for primary THA
in each category). However, the
database from which this informa-
tion was collected did not include
the type of fusion (surgical or spon-
taneous), the number of prior surgi-
cal interventions, or the type of
prosthesis implanted.
Overall, after THA for a fused
hip, patients can expect relief of
pain in adjacent joints (especially

the back), marked correction of
limb-length discrepancies, and im-
proved mobility of the hip (although
not as good as with a primary THA).
Gait quality, as well as postopera-
tive dependence on walking aids, is
related to preoperative abductor
muscle function. More than half of
patients require the use of walking
aids after the conversion THA. Full
Hip Arthrodesis
Journal of the American Academy of Orthopaedic Surgeons
252
Table 2
Long-Term Results of Conversion THA After Hip Arthrodesis
Patient Population Results
Improvement Complications
Prior Mean Age Mean Age Survivorship Good and Back Knee Disloca- Infec-
Surgical at Conver- at Follow-up at Follow-up Excellent Pain Pain tions tions
Study Fusion sion (yr) (yr) (%) (%) (%) (%) (%) (%)
Hardinge et al
27
65 75 8.2 96.4 95 80 — 0 0
(112 hips)
Strathy and 75 51 10.4 85 62.5 — — 1.2 11.2
Fitzgerald
28
(80 hips)
Kilgus et al
29

32 53 7 88 76 80 66 5 7
(41 hips)
Reikerås et al
30
— 58 8 85 85 — — — 0
(46 hips)
Hamadouche 56 55.8 8.5 96.5 91 59 45 0 0
et al
31
(45 hips)
recovery may require up to 2 years
and be associated with a prolonged,
intensive physical therapy program
that should begin preoperatively.
Survivorship of the prosthesis is
comparable to that of a primary
THA when multiple surgical proce-
dures have not been done before
conversion and if the patient is
older than 50 years of age at the
time of conversion
34
(Table 2). The
surgery is more technically chal-
lenging than a primary THA and is
associated with a higher infection
rate. The high incidence of infection
after conversion to THA may reflect
the history of sepsis or tuberculosis
in many patients who have under-

gone fusion. Although in some
studies
27-31
no infections were active
at the time of conversion, this histo-
ry is likely to affect the overall infec-
tion rate. Only one study
33
has
attempted an assessment of the rela-
tive risk of infection of conversion
surgery compared with a primary
THA. Although the higher rate of
complications should be carefully
considered and discussed with
patients before proceeding with the
conversion of a fused hip, conver-
sion remains the preferred method
to alleviate symptoms in adjacent
joints, especially if the fused hip had
been malpositioned.
Hip Arthrodesis With
Contralateral THA and
Ipsilateral Knee
Replacement
Another approach to relieve pain is
replacement of symptomatic joints if
the hip is fused in the proper posi-
tion. Garvin et al
35

reported on 20
patients (23 arthroplasties), with
follow-up ranging from 2 to 15 years.
Of the 14 replaced hips (patient age
at the time of arthroplasty, 31 to 75
years), only 10 were rated as good
to excellent. The other patients
either needed revision surgery or
still had pain in the hip or lower
back. Of the nine replaced knees
(patient age, 45 to 81 years), seven
were available for follow-up. All
required at least one postoperative
manipulation, and two patients
were not able to flex beyond 90°.
The overall complication rate was
65%. In another series
36
of 16 total
knee arthroplasties (TKAs) in pa-
tients with an ipsilateral hip fusion,
results in patients in whom the
fused hip had been converted were
comparable to those whose hips
were fused in proper position.
Rittmeister et al
37
reported on 18
patients with a fused hip. Eleven
had conversion THA only, four had

conversion THA followed by ipsi-
lateral TKA, and three had TKA
alone ipsilateral to the fused hip. Of
the hips converted, 13 were avail-
able for follow-up (average follow-
up, 45 months; average age at con-
version, 60.5 years). Eight patients
required walking aids and had a
positive Trendelenburg sign; eight
had relief of back pain; and only
two had relief of knee symptoms.
The type of hip fusion (spontaneous
versus surgical) and its duration did
not affect the outcome. The three
patients with fused hips who had
TKAs were dissatisfied with their
results; poor range of motion was
the predominant problem. Of the
four TKAs done after conversion of
the fusion, two were rated as excel-
lent and two, fair.
All three studies
35-37
on the re-
sults of TKA in the presence of a
fused hip have reported a high com-
plication rate with unpredictable
outcome. Thus, the only exception
to performing a TKA before con-
verting the fused hip would be a

patient with a satisfactorily posi-
tioned hip in whom abductor mus-
cle function was questionable. In
these patients, the results of THA
are known to be inferior, with poor
gait patterns and a decreased likeli-
hood of adequate knee pain relief.
If the hip is fused in a poor position
and the patient has significant knee
pain, the conversion THA is prefer-
able because of the notably inferior
results of a TKA in that setting.
Indications for Hip
Arthrodesis
The ideal candidate for hip arthrod-
esis is a young adult with severe
monoarticular disease, especially
posttraumatic, with high activity
demands and without preexisting
lumbar disease or ipsilateral knee or
contralateral hip arthritis. Other
potential indications are a young
patient in whom THA would be
contraindicated or would carry a
high complication rate (eg, with a his-
tory of sepsis [Fig. 1] or for salvage
of a multiply operated total hip).
Patients with polyarticular arthritis
or with bilateral developmental
dysplasia of the hips in which one

hip is symptomatic should not be
considered because of the high like-
lihood of developing contralateral
hip symptoms and degenerative
changes.
Assessment of Hip Position
The inherent inaccuracy of preopera-
tive and intraoperative assessment of
hip position in multiple planes has
been a persistent impediment to at-
tainment of optimal fusion position.
Sagittal Plane (Flexion)
Gore et al
22
flexed the normal hip
to straighten the lumbar spine and
measured the angle between the
straightened lumbar spine and shaft
of the femur. A comparison of clini-
cal with radiologic measurements
showed that radiology routinely
measured more flexion, probably
because of failure to flex the mobile
hip sufficiently to flatten the lumbar
spine completely. At the time of
fusion, the amount of flexion is sim-
ply measured by the angle formed
by the horizontal table and femoral
Paul E. Beaulé, MD, FRCSC, et al
Vol 10, No 4, July/August 2002

253
shaft. Insufficient flexion will make
sitting extremely difficult, and ex-
cessive flexion will accentuate any
shortening of the leg and put in-
creased strain on the lumbar spine.
Frontal Plane (Abduction and
Adduction)
In a neutral position, the me-
chanical axis is perpendicular to a
transverse axis through the pelvis
(through the inferior margins of
both sacroiliac joints). In this posi-
tion, the femoral shaft (anatomic)
axis has an average angle of 6° (5°
in men, 7° in women) adduction to
the vertical line representing the
mechanical axis (Fig. 2). Flexion in
the hip joint appears on an antero-
posterior pelvic radiograph as an
increased abduction angle. For
increasing flexion angles, the dis-
crepancy between actual and radio-
graphic measurements increases
and is usually 2° to 3°. According to
Lindahl,
38
adduction of 3° creates a
shortening of 1 cm, while abduction
of 3° leads to leg lengthening of 1

cm. The apparent lengthening or
shortening of the limb is purely
functional and is the result of pelvic
obliquity imposed in the frontal
plane. These two factors must be
verified when assessing hip position
intraoperatively.
Longitudinal Plane (Rotation)
Rotation of the extremity is as-
sessed visually by verifying patella
and foot orientation to the level
pelvis. Excessive internal rotation
will tend to cause the patient to con-
tinually trip over the inturned foot.
Excessive external rotation of the
extremity will load the knee in flex-
ion across the coronal plane, pro-
ducing functional problems that
cause disabling symptoms in a rela-
tively short time.
39
Slight exter-
nal rotation is desired to facilitate
putting on and taking off shoes as
well as routine foot care.
Limb Length
If leg lengths are equal preopera-
tively, the actual removal of carti-
lage as well as flexion of the hip will
produce an acceptable shortening of

<2 cm. Compensation for a preoper-
ative discrepancy of 2 to 4 cm can be
achieved by abducting the leg using
Lindahl’s measurements.
38
Exces-
sive abduction should be avoided.
For a discrepancy >4 cm, a two-
stage procedure might be consid-
ered because correction through
limb abduction or adduction should
be limited to a 2-cm difference.
Variations in abduction or adduc-
tion >6° have a negative effect on the
overall outcome of the fusion.
21,22
The two-stage technique permits
correction of limb lengths with inter-
calary grafts or other lengthening
techniques after the hip joint has
been fused in its proper position.
Recommended Optimal
Positions
A review of the literature (Table
3) suggests the following as optimal
positions for hip arthrodesis: 20° to
30° of flexion, 5° of adduction (ana-
tomic axis to horizontal line through
the pelvis), and 5° to 10° of external
rotation. In addition, leg shortening

should be minimal (ie, limb lengths
equalized within 1 to 1.5 cm). For
the range of hip flexion, the activi-
ties of the patient should be consid-
ered. For example, if the patient
spends most of the time sitting at a
desk, 30° of flexion might be the op-
timum, while 20° is appropriate for
a manual laborer who stands most
of the time.
Surgical Techniques
Although hip fusion may be an unfa-
miliar operation to many recently
trained surgeons, there are several
techniques, each with specific bene-
Hip Arthrodesis
Journal of the American Academy of Orthopaedic Surgeons
254
Mechanical axis
Transverse axis
Anatomic axis
Figure 2 Frontal plane alignment showing
the mechanical and anatomic axes.
A B
Figure 1 A, Anteroposterior radiograph of a 35-year-old man 10 years after an acetabular
fracture that was malreduced and complicated by a deep wound infection. B, Antero-
posterior radiograph 3 years after arthrodesis with anterior plate fixation.
fits and limitations. Hip arthrode-
sis
11,39

began with the development
of numerous techniques, many of
which required lengthy postopera-
tive immobilization and had high
rates of failure (up to 45%). The
double compression plate method of
Müller and, more recently, the cobra
head fixation plate
11
have provided
more viable alternatives. In choos-
ing a technique, the surgeon must
consider later conversion to THA,
missing proximal femoral bone,
limb-length discrepancies, and the
presence of an active infection.
Regardless of technique, if active
infection is present, arthrodesis
should be delayed until the infection
is quiescent (ie, normal laboratory
test results and no active drainage).
The most important factor for suc-
cess of hip arthrodesis is proper
positioning in the three planes.
Cobra Head Plate Technique
Schneider is credited with devel-
oping the cobra head plate tech-
nique, which is widely used
18,41,42
because of its reliable fusion rate

and avoidance of postoperative cast
immobilization.
11
The technique
involves stripping the abductor
muscles from the iliac crest to ac-
commodate the cobra head of the
plate together with a pelvic oste-
otomy to enlarge the area of contact
between femur and pelvis. Fusion
rates from 94% to 100% have been
reported.
40
Beauchamp et al
43
reported a
modification of this technique in a
series of 19 patients. By contouring
the plate to fit the contour of the
pelvis and proximal femur, the
pelvic osteotomy was eliminated.
In addition, instead of stripping the
abductors, the gluteus medius was
detached with a bony block and
replaced with a plate and screws at
the level of its original attachment.
All 19 patients achieved fusion.
Other surgeons have adopted the
technique.
18

Stability of the implant
is achieved by loading the plate in
tension and the bone in compres-
sion. Deficient bone stock is not
uncommon, however, which can
make the lateral tension band of the
cobra head plate mechanically
unsound (ie, with an increasing dis-
tance between the plate and the
loading axis, bending moments on
the plate are increased). The strip-
ping of the abductor muscles from
the iliac wing also can negatively
affect gait after THA conversion. A
technique that avoids the violation
of the abductor muscles would be
preferable, especially if later conver-
sion to THA is being considered.
Anterior Plating Technique
The original motivation for the
anterior approach was to create a
technique that provides fixation to
both the pelvis and femur while
sparing the hip abductor muscles.
In addition, with the patient supine
and the pelvis level during the
surgery, positioning of the hip is
facilitated. Matta et al
40
reported a

fusion rate of 83% in 12 patients
using an anterior plating technique
through a modified Smith-Petersen
approach. This technique allows
placement of the plate along the
pelvic brim immediately lateral to
the sacroiliac joint and posterosu-
perior iliac spine. With the screws in-
serted in an anteroposterior direction,
excellent purchase is achieved in
this area of thick bone, making this
technique advantageous when there
is loss of acetabular or proximal
femoral bone stock. The insertion of
a lag screw from the trochanteric
area through the supra-acetabular
bone into the center of the femoral
head provides additional compres-
sion because of a lateral tension
band effect (Fig. 3). As with other
internal fixation techniques, no ex-
ternal fixation (casting) is required
unless the patient is expected to be
noncompliant. The anterior plating
technique can also be effective in the
presence of loss of bone stock (Fig. 4).
The patient is placed in the su-
pine position on a standard fracture
table or, optimally, on a Judet table.
40

On a Judet table, the hip is placed in
the desired position before prepar-
ing the patient. An intraoperative
radiograph verifies the range of
abduction-adduction. The modified
Smith-Petersen approach involves
elevating the abdominal muscles
from the iliac crest through their
fascial attachment without violating
the abductor musculature. The dis-
tal extension is within the tensor
fascia muscular sheet, with detach-
ment of both the sartorius and rec-
tus femoris muscles. To expose the
femur, the vastus lateralis is elevated
from a lateral to medial direction to
avoid denervation. With the hip
joint exposed and denuded of carti-
lage, the lag screw is inserted first,
followed by the 12- to 14-hole low-
contact broad dynamic compression
plate. Viewed anteriorly, the plate
Paul E. Beaulé, MD, FRCSC, et al
Vol 10, No 4, July/August 2002
255
Table 3
Recommended Positions for Hip Arthrodesis
Hip Lipscomb and Alhbäck and Gore Matta Karol
Position McCaslin
12

Lindahl
21
et al
22
et al
40
et al
23
Flexion 15º–20º 40° 30º 15º–20º 20º–25º
Add/abd 0°–10º abd 0° 0°–10º add 0°–5º add 0°
External 0°–5º 5º–10° — 5º–10º Neutral
rotation
Add = adduction; abd = abduction
has a 10° concave bend to match the
internal iliac fossa, a 50° convex
bend crossing the anterior acetab-
ular rim, and a 35° concavity in the
intertrochanteric area. Usually the
plate is fixed to the pelvis first, fol-
lowed by a tensioning device ap-
plied to the distal end of the plate.
The plate may have to be undercon-
toured to avoid increasing hip flexion
as the plate is being tensioned. Iliac
crest bone graft from the inner table
may be used if necessary. Postop-
eratively, patients are usually restrict-
ed to 30 pounds of weight-bearing
for 8 to 10 weeks. After 12 weeks, if
radiographic consolidation is present,

full weight-bearing is allowed.
Double-Plating Technique
Double-plate fixation (Fig. 5) is
particularly appropriate with diffi-
cult situations such as unreduced
dislocations, avascularity of bony
surfaces, multiply operated hips, and
poor patient compliance. However,
with significant limb-length discrep-
ancy (>4 cm), the arthrodesis should
be individualized. In these situa-
tions, a two-stage arthrodesis is
often done because the capability of
hip positioning to correct significant
limb-length discrepancies is limited
by the potential negative effect on
adjacent joints (eg, increased abduc-
tion associated with low back pain).
The first stage is the preparation
of the head and the acetabulum for
fusion, usually with local fixation
and an intertrochanteric osteotomy
to remove the lever arm acting on
the desired site of fusion. In the sec-
ond stage, 6 to 8 weeks later, the
intertrochanteric area is stabilized.
By removing the lever arm of the
femur, the fusion site may heal with
greater predictability.
11

With the
patient in the lateral position, a
modified lateral approach is used;
the gluteus medius and minimus
muscles are elevated with a part of
the greater trochanter. The expo-
sure is continued anteriorly in the
plane between the sartorius and ten-
sor, with the hip flexed and exter-
Hip Arthrodesis
Journal of the American Academy of Orthopaedic Surgeons
256
Figure 4 A, Anteroposterior radiograph of a 16-year-old male with a combined pelvic and femoral neck fracture. He developed an intra-
articular infection of his left hip 6 months after injury. Anteroposterior (B) and lateral (C) radiographs 8 months after arthrodesis. The
patient maintained weight bearing as tolerated.
A B C
Figure 3 Anterior plating technique. Anteroposterior (A) and lateral (B) views of the
pelvis with optimal position of plate and lateral lag screw.
A B
nally rotated. The lateral plate
(broad 4.5 mm) is first applied and
contoured over the trochanteric bed
and placed anterior to the greater
sciatic notch and along the lateral
aspect of the femur. The plate is
then secured proximally with a ten-
sion device applied distally. After
removal of the anterior-inferior iliac
spine, the anterior plate (narrow 4.5
mm) is applied along the femoral

shaft, and a second tensioning de-
vice is applied with the plate fixed
proximally. Both tensioning devices
are then tightened; the plates tend
to lift off the bone but are reapproxi-
mated with the insertion of screws.
Postoperatively, patients are limited
to 30 pounds of weight-bearing for
8 to 12 weeks and allowed full
weight-bearing when consolidation
is evident on radiographs (Fig. 6).
Summary
Arthrodesis is a treatment option for
young adults or adolescents with
unilateral hip disease, particularly in
the presence of recent infection and
especially in the setting of failed
pelvic or hip surgery for trauma.
The ultimate goal for these patients
is a return to an active lifestyle, with
minimal restrictions and an accept-
able rate of long-term morbidity.
Arthrodesis preserves bone stock
and may provide pain relief for a
significant period of time. With
proper patient selection and the hip
fused in an optimal position, the
onset of notable pain in adjacent
joints can be delayed for up to 25
years. Current surgical techniques

for fusion allow maximal preserva-
tion of gluteus musculature, should
conversion to THA eventually be
considered. In patients older than
50 years of age, survivorship of the
conversion THA is nearly compara-
ble to that of a primary THA.
Paul E. Beaulé, MD, FRCSC, et al
Vol 10, No 4, July/August 2002
257
Figure 5 Double-plating technique. Drawings show optimal position of the plates in anteroposterior (A) and lateral (B) views and after
reattachment of the greater trochanter (C).
A B C
Figure 6 A, Anteroposterior radiograph of a 16-year-old male with a painful dislocated
dysplastic hip. B, Three years after fusion with the two-stage double-plating technique.
A B
Frontal
plane
30°
60°
Hip Arthrodesis
Journal of the American Academy of Orthopaedic Surgeons
258
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